Using Medicaid Accountable Care Initiatives to Improve Care for People with Serious Behavioral Health Conditions

Using Medicaid Accountable Care Initiatives to Improve Care for People with Serious Behavioral Health Conditions

Prepared by Wendy Holt and Richard Dougherty of DMA Health Strategies and Chuck Ingoglia and Rebecca Farley David of the National Council for Behavioral Health. 2017 ABOUT NATIONAL COUNCIL The National Council for Behavioral Health is the unifying voice of America s health care organizations that deliver mental health and addictions treatment and services. Together with our 2,900 member organizations serving over 10 million adults, children and families living with mental illnesses and addictions, the National Council is committed to all Americans having access to comprehensive, highquality care that affords every opportunity for recovery. The National Council helped introduce Mental Health First Aid USA and more than 1 million Americans have been trained. ABOUT DMA HEALTH STRATEGIES DMA Health Strategies (DMA) provides effective, data driven strategies to support health systems change and quality improvement. Its work includes strategic planning, change management and quality improvement with public and private behavioral health organizations across the country. DMA is committed to improving our nation s mental health and substance use disorder services by providing the best possible consulting services to its healthcare leaders. Since 1987, DMA has provided services that combine experience in management, organizational behavior, research methods, public policy, and systems analysis. DMA has assisted public and private agencies that offer mental health, substance abuse, medical, child welfare, and intellectual disability services. Much of its work has involved the design, procurement and implementation of managed behavioral healthcare and blended funding initiatives for states and counties. These projects have involved Medicaid, Title IV, and state and local funds for the delivery of health care to people with disabilities, special needs children, children in foster care, and individuals with mental illness and/or addictions. DMA is a leader in the implementation of self-directed care and its work also includes quality improvement collaboratives and performance measurement in publicly funded healthcare systems. Using Medicaid Accountable Care Initiatives to Improve Care for People with Serious Behavioral Health Conditions

Contents I. Context and Purpose...1 II. New and Emerging 1115 Demonstration Models...2 A. Introduction... 2 B. Accountable Care Organizations (ACOs)... 2 C. Delivery System Reform Incentive Payment (DSRIP) Waivers... 4 D. Cost-effective, Accountable Care for Population Health... 4 III. Key Aspects of ACO Design...5 A. Primary Goal of ACOs... 5 B. Service Population... 5 C. Scope of Services Provided... 5 D. ACO Lead Entity... 6 E. Payment Arrangements... 6 F. Data Sharing... 7 IV. Waiver or Contract Recommendations for Accountable Medicaid Services...8 A. Enrollment/Attribution... 8 B. Access to Services... 9 1. Outreach... 9 2. Inclusion of Behavioral Health Providers in ACOs... 10 3. Benefits and Services... 11 4. Medical Care for People with SED, SMI, and SUD... 12 5. Social Determinants of Health... 13 6. Network Standards... 13 Using Medicaid Accountable Care Initiatives to Improve Care for People with Serious Behavioral Health Conditions 3

C. Service Authorization... 15 1. Authorization of Services... 16 2. Authorization of Medications... 16 3. Appeal...17 D. Care Coordination... 18 E. Information Management... 20 1. Capabilities for Sharing Population Information... 21 2. Capabilities for Sharing Individual Client Information... 21 3. Capabilities to Share Behavioral Health Information... 22 F. ACO Governance... 22 G. Financing and Shared Savings... 23 H. Quality...24 1. Quality Measures for Behavioral Health... 25 2. Quality Measures for People with SED, SMI and serious SUD... 25 3. Cultural Competency... 26 I. Oversight...26 J. Conclusion... 27 Appendix A: Performance Measures...28 A. Well Established Measures... 29 1. Measures of Behavioral Health Service... 29 2. Measures of primary and medical care relevant for people with behavioral health problems... 31 3. Administrative Measures... 33 4. Measures of Potential Benefit... 33 B. Sources for Performance Measures... 35 1. National Sources... 35 2. State Sources... 36 3. Other Sources of Measures... 37 Appendix B: Summary of Medicaid Managed Care Final Rules...38 A. Overview of Medicaid Parity Regulations for Managed Care... 38 1. Design and Payment... 38 2. Plan Standards... 38 3. Consumer and Provider Rights and Enforcement... 39 B. Selected Provisions of the Medicaid Managed Care Final Rule... 40 1. Enrollment and Consumer Choice... 40 2. Networks...41 3. Service Authorization... 42 4. Appeals...42 5. Care Coordination... 43 6. Stakeholder Input on LTSS... 44 7. Cultural Competency... 44 8. Quality Improvement... 44 9. Regulatory Oversight... 45 Endnotes...47 ii Using Medicaid Accountable Care Initiatives to Improve Care for People with Serious Behavioral Health Conditions

I. Context and Purpose Since 2014, many states have increased their use of value-based purchasing and have begun redesigning health systems to include payment reforms and build upon local provider networks, assigning them responsibility for managing their patients care. The Accountable Care Organization (ACO) model is an approach by many public and private health systems to incentivize cost effectiveness and quality improvement. This paper addresses the design and operational features for ACOs that are necessary to ensure that they provide early identification and treatment of behavioral health conditions as well as effective care for people with complex behavioral health conditions. Today s ACOs are operating in the context of two federal regulations with a particular impact on care delivery in Medicaid. In 2016, Centers for Medicare and Medicaid Services (CMS) issued the Mental Health and Substance Use Disorder Parity Final Rule for Medicaid and CHIP (PFR), which applies provisions of the Mental Health Parity and Addictions Equity Act (MHPAEA) to Medicaid managed care organizations, Medicaid alternative benefit plans (ABPs), and the Children s Health Insurance Program 1. Previously, parity laws applied to Medicaid managed care only to the extent that behavioral health services were included in the managed care benefit. The PFR requires states to amend their state plans, if necessary, to provide Medicaid behavioral health services at parity with medical/surgical services for Medicaid managed care, ABP, and CHIP beneficiaries, as well as for any behavioral health services provided outside of these programs in the fee-for-service system. Also in 2016, for the first time in 14 years, CMS revised regulations for Medicaid managed care. This rule sets standards that protect Medicaid enrollees served through managed care in a number of ways, including establishing an expansive medical necessity standard. It also requires health care plans to provide information to assist consumers in making informed choices between managed care organizations (MCOs); states to establish time and distance standards for plan provider networks; Medicaid health plans to spend at least 85% of payments on services and quality improvement; health plans to address the special needs of people who need or use Long Term Services and Supports (LTSS); and states to draft, implement and update a comprehensive quality plan for managed care every three years. (The provisions of these two new regulations with particular relevance for Medicaid enrollees with behavioral health needs are summarized in Appendix B.) Both CMS and the states increasingly recognize behavioral health services as a critical component of care for Medicaid members. While some Medicaid ACOs do not include behavioral health services, many require behavioral health services and providers to be included and measure the quality of behavioral health care as part of performance incentives. Some go further, and provide the option for inclusion of non-medical community services that are of significance for Medicaid members. This paper primarily addresses the ACO model and how it can be used to best meet the needs of children with serious emotional disturbance (SED) and adults with serious mental illness (SMI) and/ or serious substance use disorder (SUD). The paper is a resource for administrators, providers, health advocates and others in states that are considering health system reforms for their public and private health systems. It draws upon what has been learned about Medicaid ACOs and makes recommendations about how states can ensure that their Medicaid health system addresses the behavioral health needs of all their members. Using Medicaid Accountable Care Initiatives to Improve Care for People with Serious Behavioral Health Conditions 1

II. New and Emerging 1115 Demonstration Models A. Introduction Section 1115 Waivers are a key tool allowing states to design alternative ways to deliver Medicaid services that differ from federal program rules, including by implementing ACOs. Section 1115 initiatives waive specified rules so that states can conduct experimental, pilot, or demonstration projects that are consistent with the objectives of the Medicaid program. Most demonstration models discussed here use 1115 Waivers. These waivers are required to be budget neutral, meaning that federal spending under the waiver should not exceed expected federal spending if the waiver was not in place. Even with increasing enrollment of Medicaid beneficiaries into managed care, the costs of health care and coverage have continued to rise, while quality and outcomes are not increasing. In response, all sectors of the health care system have had to redouble their commitment to achieving the Triple Aim: improving the patient experience of care, improving the health of populations, and reducing the per capita cost of health care. There is now a concerted effort across private and public payers to move toward alternative payment methods that reduce incentives for overuse and increase incentives for quality and outcomes. This approach has produced new models for organizing and financing service delivery. Two are of particular relevance here: ACOs and Delivery System Reform Incentive Payments (DSRIP). B. Accountable Care Organizations (ACOs) According to the Kaiser Commission on Medicaid and the Uninsured, an ACO is a provider-run organization in which the participating providers are collectively responsible for the care of an enrolled population, and may also share in any savings associated with improvements in the quality and efficiency of the care they provide. 2 This model was first used by commercial plans and then gained more widespread use in Medicare. Payment reform efforts and 1115 Waiver authority have significantly expanded the focus on ACOs in Medicaid; the discussion here will concentrate on Medicaid ACO models. With a goal to cultivate and expand provider-run ACOs, states are developing strategies for bundled payments, and some are pursuing incentives around the total cost of care. To ensure that financial incentives do not result in failure to provide needed care or provision of low-quality care, payment also depends on achieving goals for quality of care and client satisfaction. ACOs that fail to meet quality standards may lose a share of the savings they would otherwise be entitled to. Monitoring ACOs performance requires considerable data collection and reporting capacity across participating providers. In addition, achieving well-coordinated, safe and effective care requires well developed health information systems capable of interoperability and information exchange between ACO partners. 3 Medicaid ACOs generally use two value-based payment structures: capitated budgets and shared savings. Capitated Budgets: Like MCOs, many ACOs are paid a capitated per patient per month rate for a specific group of patients, and have full financial risk for their costs of care. 4 Large provider systems may serve as ACOs, but in many cases, an MCO partners with a group of providers to form an ACO, since the MCOs have the utilization management and claims payment infrastructure needed to take on the role of serving as payer. 5 In Oregon, a regional care coordination organization plays this role. 6 Enrollees are prospectively assigned to capitated budget ACOs, and the Medicaid enrollees participating in capitated budget ACOs vary considerably based on state design. 7 2 Using Medicaid Accountable Care Initiatives to Improve Care for People with Serious Behavioral Health Conditions

Shared Savings: Similar to the Medicare ACO model, Medicaid ACO providers can share in savings in the total cost of care (TCOC) of their attributed members. Most Medicaid enrollees in shared savings models who access primary care through an ACO provider are retrospectively attributed to the ACO based on their primary care provider s affiliation. As a result, the costs and quality of their care are counted in ACO results. 8 The ACO is responsible for the TCOC whether services are provided inside or outside of the ACO, thereby promoting development of its ability to manage and coordinate care with its different providers. Indeed, through retrospective assignment, the ACO may not know all of the Medicaid members that will be attributed to their organization. Savings are calculated against a predetermined baseline of expected expenditures. In some cases, providers may also share part of the excess cost if expenditures exceed the baseline. 9 Shared Savings model ACOs are almost always solely provider organizations since insurance licensure is generally not required under this type of reimbursement and the attribution approach. ACOs are entities that include providers as part of a formal organization that bears risk and shares savings among members. They must have sufficient capital to cushion possible losses. In higher-risk, fully capitated models, some provider groups are partnering with insurers to access capital. 10 ACOs vary in the services they are expected to manage. As of January 2017, four state Medicaid ACO models covered only physical health services, and a fifth had the option to cover behavioral health services. Five others included behavioral health, with some of them including long-term services and supports (LTSS), dental, and sometimes even housing or other social services. To date, Medicaid ACOs have had impressive results. For example: Oregon Coordinated Care Organizations (CCOs) have achieved significant improvements on a number of dimensions, while successfully holding cost growth to the required 2% target. o As of mid-year 2016, 9 of 16 CCOs met the follow-up after hospitalization for mental illness target of 79.9%; o On average, 16.3% of members (ages 12+) had appropriate screening and intervention for alcohol or other substance abuse, exceeding the 2016 benchmark of 12.0%; o 63.3% of children received follow-up care after being prescribed ADHD medication, exceeding the 2015 national Medicaid 90th percentile of 53.0%; and o 17.7% of members (ages 13+) had two or more additional services for alcohol or other drug dependence within 30 days of their initial treatment, exceeding the 2014 national Medicaid median of 11.3%. 11 Through 2015, Minnesota s Integrated Health Plans (IHPs) have helped the state save $156 million. Increased integration of behavioral health services and community partnerships were among the drivers of success. 12 Launched in 2014, the Vermont Medicaid Shared Savings Program (VMSSP) reported $14.6 million in savings in the first year. 13 Colorado reported that its Accountable Care Collaboratives (ACC) generated net savings of $29 to $33 million during FY 2014, its third year of operation. 14 Using Medicaid Accountable Care Initiatives to Improve Care for People with Serious Behavioral Health Conditions 3

C. Delivery System Reform Incentive Payment (DSRIP) Waivers DSRIP is a payment method built into some waiver programs that provides states with funding to support the investments needed to contain total health care costs over the life of the 1115 waiver. Examples include New York, Texas, Washington and Massachusetts. Recognizing the up-front investments that many delivery systems need, DSRIP waivers allow states to receive a portion of their future savings in the initial years of the waiver. States can use DSRIP payments to support hospitals, community mental health centers and other behavioral health providers in changing how they provide care to Medicaid beneficiaries. So far, there are relatively few DSRIP waivers in place, though others are in the pipeline. The overarching goal of these programs is to achieve measurable improvements in quality of care and population health through transforming payment and delivery systems. All current DSRIP programs include public hospitals, with some including private hospitals and two including non-hospital providers. DSRIP initiatives are multi-year performance-based incentive programs and come with the requirement to achieve significant improvements in future years on reduced levels of federal match. Required performance generally focuses first on achieving infrastructure development benchmarks, then system redesign goals, followed by clinical outcome improvements, and finally improved population health outcomes. Measures of clinical and population health outcomes may require providers to develop substantial new reporting capacity. 15 D. Cost-effective, Accountable Care for Population Health Overall, these new Medicaid payment models explicitly focus on changes in the provision of care that should be of great value to enrollees with disabilities, mental illnesses, addictions and other complex conditions. Nonetheless, states must use caution as they initiate system change to ensure that providers and other organizations are able to systematically build their capacity for improved care coordination in ways that maintain the existing behavioral health service system and sustain relationships between Medicaid members with complex behavioral health conditions and their providers. To achieve the longerterm goals of population health improvement will require effective delivery systems for people with the most serious behavioral health conditions, but also health education and cross sector actions to address many of the social factors leading to poor health. Achieving accountability and reducing future costs of health care services requires up-front investments in workforce skills, technology and care coordination, particularly in transitions between levels of care. It will require plans for health systems that build on the strengths of existing local providers and community agencies. States need to develop rate methodologies and contract requirements that ensure these investments occur and that their results are measured. 4 Using Medicaid Accountable Care Initiatives to Improve Care for People with Serious Behavioral Health Conditions

III. Key Aspects of ACO Design The primary goal for ACOs is to drive care coordination to the provider level to be carried out in collaboration with the client. ACO payments and standards are generally designed to incentivize and empower medical providers to undertake care planning and coordination based on their face-to-face relationship with clients. This requires care coordination with other providers through ACO network membership and partnership agreements. This chapter identifies some of the key design decisions that states must make, and provides examples from the first Medicaid ACOs. A. Primary Goal of ACOs States must set goals for their ACOs. Aligning Medicaid ACOs with the priorities and measures used by Medicare and Commercial ACOs provides consistency for providers and makes it more likely that they will make progress on shared priorities. However, Medicaid members have special needs that are distinct from the Medicare and commercial populations. States need to ensure that ACOs will effectively address these needs. All states must find an appropriate balance between alignment with other payers and appropriate focus on the special needs of the Medicaid population. Vermont has emphasized aligning Medicaid and Exchange ACOs with existing ACOs for Medicare and commercial payers into an All-Payer model, which may lead to transformations that cut across the entire health system. In contrast, Oregon has developed specialized statewide Medicaid ACOs based in health plans with many contractual provisions focused on meeting the needs of the Medicaid population, and strengthening relationships with county-based health and preventive services. B. Service Population States must decide which Medicaid members will be attributed to ACOs for measurement purposes. This is a different process than the customary enrollment methods associated with managed care and capitated financing. Capitated budget ACOs, and those that serve a specific geography, have members attributed or enrolled prospectively based on member selection, or when a specific geography is served, based on location of residence. Members are attributed to most shared savings ACOs retrospectively based on members utilization of ACO services. One challenge in retrospective attribution is that providers in the ACO network don t always know whose care they are accountable for. Capitated budget ACOs are generally restricted to Medicaid-only members, while some shared savings ACOs have also included people who have both Medicaid and Medicare coverage. Systems for these dually eligible consumers (Medicare and Medicaid) are challenging because Medicare savings (inpatient and pharmacy) accrue solely to Medicare or its MCOs; there has not been a mechanism for sharing that portion of savings with states except in some demonstration waivers. Thus, states have often had to develop two accountable care models. Illinois, for instance, has procured specialized Care Coordination Entities (CCEs) that serve children with complex medical needs or people who are elderly and disabled, and Accountable Care Entities (ACEs) that serve other Medicaid members. 16 C. Scope of Services Provided As Medicaid programs have begun to incorporate accountable care strategies, they have often selected different sets of services to be managed. Medicaid services not included in the ACO are accessed with self or provider referrals using existing procedures. Colorado s Regional Care Coordination Organizations are geographically based providers delivering care coordination and practice support for Primary Care Medical Providers (PCMPs). The other states ACOs all include physical health services, with some requiring or allowing provision of additional services, including behavioral health, dental, and LTSS. As an Using Medicaid Accountable Care Initiatives to Improve Care for People with Serious Behavioral Health Conditions 5

example, Maine includes most Medicaid services in the TCOC for its Accountable Communities, but ACOs may elect to include adult family care homes, assisted living services, Day Health, HCBS Waiver Services, Intermediate Care Facilities for Individuals with Intellectual Disabilities (ICF/IID), Long Term Care, Nursing Facility, Personal Care, Private Duty Nursing, Children s Private Non-Medical Institutions, and dental. 17 With growing recognition of the significance of social determinants of health among the Medicaid population, states are increasingly expecting ACOs to establish strong collaborations with social services and community-based health-related services. Oregon s CCOs are mandated to work with county health departments and other community organizations in their region, conducting regional health assessments and developing services to meet unaddressed needs. Minnesota requires ACOs to coordinate with county health services and has encouraged them to include community service providers in their governance boards. In fact, a county-based safety net ACO is considering leasing housing for homeless members. At least one ACO contract specifically allows ACOs to pay for non-medical care that would have an impact on members health. D. ACO Lead Entity ACOs generally need a lead administrative and financial entity, which will contract with the state, submit bills, and accept payment on behalf of the ACO. Depending on the level of financial risk involved and the scope of reporting required, some states have designated MCOs (or the equivalent) to lead ACOs, making MCOs responsible for developing shared savings arrangements with providers and working together toward desired quality outcomes and cost targets. This also would allow the ACO to operate under the MCO s licensure as a managed care organization. Other states have excluded MCOs from participating in ACOs. In these states, providers organize and lead ACOs in each region or community. For instance, Illinois allows a wide range of entities to serve as the legal entity responsible for contracting with the state, including a Medicaid-enrolled provider, a non-medicaid enrolled provider, or a local governmental non-medicaid authority, and the ACO lead can be a for-profit provider. 18 Minnesota has defined virtual ACOs as physician groups without hospital participation that serve smaller numbers of members and carry no risk. Finally, some ACOs are geographically based. The ACO is required to serve a specific catchment area, often with considerable coordination with county public health and other community organizations. When ACOs are led by providers, they are usually considered to be exempt from insurance or managed care licensure. However, in some states, ACOs may need to obtain licensure in part because of the level of risk involved in the financing. 19 A discussion of legal issues related to ACOs is beyond the scope of this document; additional information is available from The ACO Handbook: A Guide to Accountable Care Organizations, Second Edition. 20 E. Payment Arrangements Most ACOs are funded with capitated budgets, some sort of shared savings, or performance incentives. CMS requires that capitated budgets be actuarially sound, with any expected savings built into the payment method. This form of payment provides both the state and the ACO with greater certainty on the program s costs. Any savings beyond those built into the capitated budget will automatically be retained by the plan; however, there is an expectation that the plan will have shared savings arrangements with its component providers. Shared savings are based on a projection of what costs would be in the absence of the ACO. At the end of the period, actual costs are compared to this cost projection; if the agreed upon savings are realized, they will be shared between the ACO and the state. Some ACOs, primarily health plans and larger ACOs, also take on risk for exceeding expected costs and are expected to absorb a share of any overage. 6 Using Medicaid Accountable Care Initiatives to Improve Care for People with Serious Behavioral Health Conditions

All models link payment to performance. ACOs must establish measures of quality care provision, report on baseline performance, and achieve a certain minimum improvement or reach an established goal in subsequent years. In some ACOs, the amount paid for performance is based on a small withholding from the capitated budget. In addition to incentivizing efficient and effective provision of care, ACO models may incentivize other potential outcomes, based on the payment model. When ACOs can influence what clients they serve, capitated budgets incentivize them to serve low-cost clients, whose average cost is less than the capitation payment. In contrast, shared savings payments incentivize providers to serve high-cost patients whose costs they can reduce. The Medicaid landscape is currently dominated by managed care, with 77% of Medicaid members across the country enrolled in a managed care plan in 2014. 21 Making changes to these insurance markets will be challenged from consumer advocacy, health policy, financial and political perspectives. As a result, states must be very clear about the boundaries of these new Accountable Care Organizations and clarify how ACOs and MCOs will relate to each other in the marketplace. When MCOs are the ACO lead entity, they are expected to develop shared savings arrangements with provider members. If MCOs are not an ACO participant, but have provider-led ACOs in their network, those ACOs may be able to lower costs for the MCO. States are empowered by the Medicaid managed care final regulation to require their MCOs to participate in value based purchasing and delivery system reform, and should determine whether MCOs are required to share their savings with ACOs. 22 For example, Minnesota MCOs are required to share savings with ACOs in their networks, while New Jersey allows ACOs and MCOs to negotiate their own shared savings agreements. F. Data Sharing Through their utilization management and claims systems, MCOs have access to utilization and cost information on all the services in their benefit package. This information can help them identify members who could benefit from care coordination or those whose costs of care could be reduced without threatening quality, and also provide real-time or timely information on which providers are serving a specific member. With care coordination being pushed down to the provider level, providers in ACOs need access to this kind of information. Some ACOs are developing shared electronic health records (EHRs) among their participating organizations to provide such information. In ACOs with large networks, this may provide most of the information care coordinators need. However, smaller ACOs will need to be able to get information on their patients served outside of the ACO network. States have developed different arrangements to share relevant claims information from their own systems with ACOs. The state may do this by requiring MCOs to share data from their claims or Utilization Management systems, contracting an IT service to produce and disseminate the state s own data, or producing and sharing the reports itself. States need to work closely with MCOs and providers to develop data collection and exchange protocols that are clearly understood, efficient, result in useful information and align with providers other reporting requirements. Using Medicaid Accountable Care Initiatives to Improve Care for People with Serious Behavioral Health Conditions 7

IV. Waiver or Contract Recommendations for Accountable Medicaid Services This chapter addresses specific health system design and performance requirements for ACOs; specifically, the key ACO functions that should be considered for Medicaid members with behavioral health conditions based upon different levels of financial accountability and risk. Whatever its level of risk, an ACO s individual, family and community health outcomes should be frequently, regularly and publicly reviewed during implementation. A. Enrollment/Attribution States have a number of options for determining which Medicaid members an ACO will serve, whether participation is mandatory or optional, and how long members remain eligible. Many states attribute members based on their use of a primary care practice that is part of the ACO. Members retrospectively attributed to an ACO may not be aware that they are enrolled in an ACO. Nonetheless, it is important that they be informed of their participation and their rights within it. States should: When members are required to select an ACO, provide outreach and enrollment assistance tailored for people with SMI or serious SUD to help them select an ACO and a primary care provider. Behavioral health providers should be considered to perform some of this outreach. 23 When members are assigned to an ACO, clearly notify enrollees when they have been assigned, and provide information about what an ACO does and their options to opt out or change ACOs. 24 When members opt out of an ACO, provide outreach and assistance to enroll in another managed care plan or ACO and to select other primary care and behavioral health providers, if necessary. Specify member rights to change ACOs. Examples Illinois specialized Care Coordination Entity (CCE) for Children with Complex Medical Needs determines eligibility based on children s scores on clinical risk grouping software, and it intends to develop a clinical screening tool for children who do not have sufficient claims to use the grouper. 25 Children are eligible for three years, and must then be reassessed for eligibility. While CCEs can target particular conditions, they must accept any child meeting eligibility standards. Participation in a CCE is voluntary, and the family has the option to drop out or change the CCE without cause during the first 90 days of enrollment. Thereafter, the child is locked in to his or her selected CCE for 12 months until the annual enrollment period. In addition to attribution based on primary care utilization, Maine attributes members to ACOs if they have had three or more ED visits with a hospital that is part of an ACO. 26 Colorado Medicaid members are not enrolled with a Primary Care Medical Provider (PCMP) if they have a clear pattern of use with a provider who does not serve as a PCMP. Members without a provider relationship are enrolled with the Regional Care Coordination Organization, which is responsible for connecting them with a PCMP. 27 8 Using Medicaid Accountable Care Initiatives to Improve Care for People with Serious Behavioral Health Conditions

B. Access to Services A number of dimensions of ACO design and functioning have bearing on access for Medicaid members with SED, SMI and/or serious SUD. These include: outreach to members who are disengaged from the service system; participation and inclusion of behavioral health providers in the ACO; participation in capitated budget ACO networks; and the scope of services for which the ACO is accountable. Access to primary and medical care is an important issue for this population, as much as their behavioral health care. 1. Outreach Many people with complex behavioral health conditions are not engaged in a primary care relationship, and some are not engaged in ongoing behavioral health treatment. Outreach and engagement services must be built into any service system for these members. ACOs do not have a natural incentive to reach out to unengaged Medicaid members. Provider-led ACOs will have members assigned retrospectively based on their use of ACO services. It will be much easier for them to serve motivated patients who regularly participate in care. Capitated budget ACOs will generally receive a capitation payment whether a member uses services or not. They might actively reach out to those unengaged members who frequently use crisis care, emergency care, detoxification and inpatient care to move them toward less costly use of services, but they do not have a financial incentive to reach out to those who are simply going without care. For this reason, it is important for states to build in requirements or incentives for ACOs to assertively reach out to all their members and work to engage them in ongoing care. States should: Establish a clear requirement for ACOs to serve members who are unengaged in behavioral or medical care, and continue to reach out to them creatively and assertively. Require ACOs to purchase services from or establish partnerships with community behavioral health providers who provide assertive outreach to engage people with SMI or SUD who are not regularly participating in treatment. Include measures of primary care and behavioral health penetration as quality goals to incentivize outreach to underserved populations. Even better, measure penetration for specific populations, including unengaged people with behavioral health or other underserved conditions. Permit and encourage the use of behavioral health peers and community health workers to perform outreach and engagement. When providers continue to be paid fee-for-service, reimburse for the work of behavioral health peers and community health workers performing outreach and engagement. Incorporate outreach and engagement as an expected component of care coordination. Examples Minnesota specifically allows ACOs to use community health workers, navigators and peer counselors. In Oregon, a CCO s payment is based on members ratings of access to care, the rate of adolescent well-care visits, and emergency department utilization. Though not considered in quality payments, Oregon requires ACOs to report a number of additional measures, some of which are stratified for people with mental health diagnoses. These measures address aspects Using Medicaid Accountable Care Initiatives to Improve Care for People with Serious Behavioral Health Conditions 9

of behavioral health care as well as access to medical and dental care. Several of these measures are also stratified for people with SMI, ensuring that the care received by these groups is well monitored, and disparities in access and quality between people with mental health issues and those without is addressed. 2. Inclusion of Behavioral Health Providers in ACOs Behavioral health is a known driver of Medicaid expenditures, and community mental health and addiction treatment providers are uniquely qualified to address the special needs of people with complex behavioral health conditions. For this reason, states should define a formal role for providers serving Medicaid members with complex behavioral health conditions. CMS has prohibited behavioral health providers from serving as lead entities for ACOs; however, as listed below, there are a number of approaches that states can take to include community mental health and addiction treatment providers in ACOs. States can: Require or incentivize ACOs to include behavioral health and other community providers used by people with complex conditions as members of the ACO, participating in shared savings. Require ACOs to include one or more community behavioral health providers on their governance body. Establish a role for community behavioral health providers as the source for specialized care coordination for people with complex behavioral health needs, either within an ACO or as an entity with which an ACO must collaborate. Require or incentivize ACOs to collaborate with community behavioral health providers serving their members. Require ACOs to develop an advisory group or groups representing community behavioral health providers and members with SED, SMI and serious SUD. Examples Maine requires an Accountable Community to include at least one provider for behavioral health, one for chronic conditions, and one for developmental disabilities, if there is such a provider in its service area. Minnesota s ACO program requires its Integrated Health Plans (IHPs) to demonstrate how formal and informal partnerships with community-based organizations, social service agencies, counties, public health resources, etc. are included in the care delivery model. IHPs are encouraged to propose mechanisms to incorporate these organizations directly into the payment model and are awarded bonus points for doing so. 28 Minnesota s IHPs must have a Medicaid-enrolled provider to serve as the entity that receives payments or pays cost sharing, but non-profits, a county, or group of counties can be part of the IHP. Illinois allows a wider range of organizations to serve as a lead entity of a CCE, including health care organizations, non-health organizations, governmental entities and for-profit providers. Maine allows any provider judged through an application process to be willing and qualified to be a lead entity for an Accountable Community (AC). 10 Using Medicaid Accountable Care Initiatives to Improve Care for People with Serious Behavioral Health Conditions

Massachusetts Medicaid agency will select community behavioral health providers on a competitive basis to serve as Behavioral Health Community Partners, and its ACOs must contract with the Behavioral Health Community Partners serving its catchment area. Behavioral Health Community Partners will be paid separately on a capitated basis for providing enhanced care coordination for members with SMI and serious SUD. In addition, Behavioral Health Community Partners will receive up to $450,000 in DSRIP funding to support infrastructure development needed to fulfill their care management responsibilities for ACO members. 3. Benefits and Services States must decide on the scope of services that ACOs will be responsible for providing, as well as the scope of services for whose total costs they will be accountable. Some states focus solely on medical care in ACOs, while most at least make it optional for ACOs to include behavioral health, or plan to phase it in over time. Long-term services and supports are less frequently included. Oregon s initiative is the most inclusive, comprising medical, behavioral health and dental services. Any service boundaries established between ACOs and other entities should not become an impediment to access for members who need those services. On the other hand, ACOs will have a financial incentive to substitute external services for those services which the ACO pays or is otherwise accountable. States should both require ACO care coordination to facilitate access to excluded services, as well as control or monitor access to excluded services to prevent inappropriate cost shifting. In regard to inclusion of behavioral health, states should: Promote access to both medical and behavioral health care for members with SED, SMI and serious SUD by including or phasing in inclusion of Medicaid behavioral health services in those services expected to be delivered by ACOs as well as in the TCOC. Allow behavioral health homes, behavioral case management or care coordination providers, and integrated primary care case management practices to participate in ACOs, and award bonus points for ACO applicants that have included them. Provide extra points for ACO applicants based on their plans to share savings with behavioral health providers, or establish other financial incentives for managed behavioral health care organizations or participating behavioral health providers. When inclusion of behavioral health is optional for ACOs, provide bonus points for ACOs that opt to include them. Establish financial incentives and quality measures related to effective identification and treatment of behavioral health problems. If ACOs are not yet ready to manage behavioral health services, phase those services in over time. In regard to inclusion of behavioral health LTSS in ACOs, states should: Require ACOs to provide Medicaid-financed behavioral health LTSS and be accountable for total costs. Assess early experience with including LTSS in ACOs. Based on results, consider braiding funding for non-medicaid LTSS into ACOs or otherwise aligning provision of Medicaid and non-medicaid LTSS. Using Medicaid Accountable Care Initiatives to Improve Care for People with Serious Behavioral Health Conditions 11

Provide extra points for ACO applicants based on their plans to manage behavioral health LTSS for people with SMI. Provide extra points for ACO applicants based on their plans to share savings or establish other financial incentives for participating behavioral health LTSS providers based on improving community tenure and participation for people with SMI. Consider calculating and sharing savings from reductions in institutional care with organizations responsible for managing behavioral health LTSS. If behavioral health LTSS are provided outside of ACOs, require them to develop protocols to coordinate referrals to LTSS. Monitor use of LTSS to identify access problems or cost shifting from ACOs to LTSS. Examples The Maine Accountable Community Initiative builds on its health homes and behavioral health homes by requiring any Health Home Practice s partner(s), such as a Care Coordination Team or a Behavioral Health Home Organization, to participate in the AC. The TCOC for Massachusetts ACOs will eventually include physical health, behavioral health and LTSS. 4. Medical Care for People with SED, SMI and SUD The flexibility inherent in the ACO model empowers states to eliminate or address barriers to effective medical care for people with SED, SMI and serious SUD. States should: Establish incentives for ACOs primary care practices to treat this high-risk group. Eliminate any regulatory barriers to the provision of co-located primary and behavioral health care, such as conflicting licensing regulations for primary and behavioral health facilities and restrictions on same-day billing of more than one service. Encourage ACOs to compensate primary care providers for the extra time spent working with members with mental health or substance use problems. Encourage ACOs to use peers and behavioral health care managers to assist members with behavioral health conditions to get medical care. Allow ACOs to use their reimbursement to pay for the expenses of self-management programs to address physical and mental wellness, including smoking cessation and weight loss, for individuals with SED, SMI and SUD. Develop measures to monitor the provision of medical care for members with SED, SMI or SUD. 12 Using Medicaid Accountable Care Initiatives to Improve Care for People with Serious Behavioral Health Conditions

5. Social Determinants of Health In addition to considering the inclusion of community service providers in ACOs, ACOs should be attentive to a member s social needs in service planning and care coordination. States should: Require ACOs to be knowledgeable about the needs of the community and have relationships with organizations that address members social needs. 29 If ACOs need additional time to develop this capacity, expectations should be phased in. Require ACOs to complete a needs assessment and community health improvement plan that engages community-based organizations and populations served. 30 Require that ACOs demonstrate progress in implementing community health improvement plans. 31 Examples Oregon Care Coordination Organizations must conduct a needs assessment and implement a community health improvement plan. 32 Minnesota requires its ACOs to Demonstrate how formal and informal partnerships with community-based organizations, social service agencies, counties, public health resources, etc., are included in the care delivery model. Responders are encouraged to propose mechanisms to incorporate these organizations directly into the payment model. 33 Minnesota s ACO assessment tool guides practices toward the goal of formalized partnerships with community agencies supported by an infrastructure where partners plan together, measure outcomes together, and share information together. 34 6. Network Standards States set network standards for adequacy, credentialing, travel time/distance and time from request to appointment for its MCOs, and with implementation of the Medicaid managed care final regulation, CMS must approve them. States will need to determine how these standards apply to ACOs. ACOs led by health plans will likely adhere to similar standards. Provider-led ACOs will have a group of providers participating in the ACO, may have a network of providers partnering in other ways, and their members will also have access to the providers participating in the larger Medicaid system. In such cases, states will have to consider what kinds of network standards ACO participants and/or partners should meet. For people with complex behavioral health problems, standards for access to primary care, behavioral health services, and peer support services should all be addressed. In regard to primary care, states should: Require ACOs to offer members a choice of primary care providers. 35 Require ACOs to contract with or include both integrated primary care practices (such as community health centers) that currently treat individuals with SED, SMI and SUD, and behavioral health providers with co-located primary care. Require ACOs to develop plans to increase the network of primary care providers who are Using Medicaid Accountable Care Initiatives to Improve Care for People with Serious Behavioral Health Conditions 13

prepared to welcome and serve people with SED, SMI and SUD. Prohibit ACOs from excluding or discriminating against providers that serve high-risk populations. Require or incentivize ACOs to contract with or include all willing physicians in their service area who are certified and willing to administer buprenorphine, unless they do not meet other minimum standards. Require ACOs to set a standard for the number of complex cases that a primary care practice offering care coordination can appropriately carry. Set appointment access standards for ACOs that are aligned with those that the state sets for MCOs. Prohibit ACOs from setting rules for payment that inhibit co-location and integration of primary care and behavioral health care, such as prohibiting billing of two services on the same day. In regard to behavioral health providers, states should: Require ACOs to include community mental health and addiction providers as partners or affiliates and recognize the state s licensing standards for mental health and SUD services as necessary and sufficient for credentialing. To expand their networks, require ACOs to develop streamlined methods to credential 36 Master slevel behavioral health clinicians who are not yet licensed or have three years of experience, including substance abuse counselors, direct care and peer/recovery staff. Require ACOs to include providers with expertise in the needs of children subjected to abuse and/ or neglect. Require ACOs to offer members with SED, SMI, or SUD a choice of community providers and a choice of case managers. 37 Limit ACOs ability to build duplicative behavioral health services that could threaten the continued viability of community behavioral health organizations. Require or incentivize ACOs to credential and contract with community behavioral health providers as an organization, rather than only with licensed staff. Require or incentivize ACOs to recognize state SUD credentials for non-master s trained counselors. Require ACOs to use certain specialized behavioral health services, such as mobile crisis teams, that require a sufficient volume to succeed. Establish expectations or contractual requirements for ACOs to coordinate with services provided outside of the Medicaid system, such as those provided by a state or county MH, SUD, or developmental disabilities agency. Encourage appropriate use of telehealth services for psychiatry and other hard-to-access behavioral health providers. 38 Set appointment access standards for ACOs that are aligned with those that the state sets for MCOs. 14 Using Medicaid Accountable Care Initiatives to Improve Care for People with Serious Behavioral Health Conditions www.aacap.org/aacap/advocacy/federal_and_state_initiatives/workforce_maps/home.aspx